It is a pleasure to serve with you in the Chair, Mr Rosindell. May I say how glad I am to have secured this debate during Eating Disorders Awareness Week? I am glad that we have the opportunity to talk about how people acquire eating disorders and how they can, or should, be able to get the help they need.

Let me place on record my thanks to all the people and organisations who helped me to prepare for this debate. It is a long list, so I hope hon. Members will bear with me, because they deserve to be highlighted: Sandie Atkinson from Diabetics with Eating Disorders, Beat Eating Disorders, the Royal College of Psychiatrists, the British Psychoanalytic Council, the Musicians’ Union, Equity the acting union, the British Dietetic Association, Professor Khalida Ismail of King’s College, London, Hope Virgo of the Dump the Scales campaign, the Priory Group, the House of Commons Library, which has produced a really good briefing, as always, the Parliamentary and Health Service Ombudsman, which has also provided a briefing, and Julia Tyson.

Some 1.25 million people are living with an eating disorder, 10% of whom suffer with anorexia nervosa, and 40% with bulimia; the remainder suffer from other forms such as binge eating. Research shows that the earlier the treatment is accessed, the better the chance of recovery. The figures show that 50% recover and 30% experience some improvement. Worryingly, however, 20% remain in a chronic condition. The most common age of onset is 15 to 25, although there is growing evidence that older people are affected as well.

I want to touch on three areas: first, diabulimia, which is a form of eating disorder that many may be unaware of; secondly, the interplay between the entertainment industry and social media, and the impact they have on people’s sense of their own appearance; and thirdly, treatment.

Diabulimia is a form of eating disorder that affects thousands of people with type 1 diabetes. We cannot give an accurate figure, because of how incidents are recorded—it will show up as an eating disorder but not necessarily for somebody who has diabetes. Simply by withholding insulin, type 1 diabetics are able to attain rapid weight loss. There are, however, serious physical health consequences, and it can be fatal. I will not say too much on this topic, although I will return briefly to it later, other than that Mrs May has agreed to co-chair an inquiry into this matter with me, which we hope to commence later in the year. The right hon. Lady and I intend that the inquiry will raise awareness of diabulimia and look at evidence of what practical steps can be taken to improve the treatments available.

The relationship between the entertainment industry and eating disorders is complex but real. It has been described as a vicious circle, whereby some musicians and actors are put under pressure to look a certain way. In many well-documented cases they subject themselves to eating habits that, as they see it, enable them to achieve that appearance. However, that is not without consequence for their mental and physical wellbeing.

Let me explain what I mean. The actress and Equity activist Jean Rogers has drawn my attention to the work of Dr Sara Reimers of Royal Holloway, University of London, on aesthetic labour, which is defined as

“employers intentionally use the embodied attributes and capacities of employees as a source of competitive advantage.”

That work formed the basis of the “Making an Appearance” research she conducted with the Equity women’s committee.

Maureen Beattie, the president of Equity, has given an account of her own eating disorder as an actress, which she struggled with from the age of 14 to 30. She said:

“When I was at drama school I found the mixed messages I received very confusing—on the one hand I was told I was a big, fat lump of a girl and on the other hand was always cast in leading lady roles which required elegance and charm and attractiveness. There was a lot of pressure on me to lose weight, but the more the staff (and my parents who were both in the entertainment industry) lectured me about my weight the more I needed to eat. I ate so much I sometimes felt like I had been drugged. I realise now I was protecting myself”.

She says that the pressure of acting contributes to eating disorders:

“The feeling of being an object to be pushed and pulled and commented on and criticised and laughed at by the public is very real to many people.”

“I was described as the plain one at the back…I ended up making myself really ill. I was anorexic for a few years. I was exercising obsessively, and I ended up being incredibly depressed. I was in denial.”

After being diagnosed, she described going from anorexia

“to having a binge-eating disorder”.

Tellingly, she concluded that her

“appearance began to change, which was the biggest fear”.

In the documentary “Miss Americana”, the hugely successful international singer Taylor Swift talked about how, as an 18-year-old, she was portrayed on the cover of a magazine. She said:

“The headline was ‘Pregnant at 18?’ and it was because I had worn something that made my lower stomach look not flat. So, I just registered that as a punishment”.

Consequently, she said of her performances that she

“thought I was supposed to feel like I was going to pass out at the end of a show, or in the middle of it”.

It is not only young women who are affected by eating disorders—the singer Sam Smith has talked about starving for weeks to prepare for photoshoots.

A 2016 Credos survey of 1,000 boys aged between eight and 18—“Picture of Health?”—found that 55% would consider changing their diet to look better. Interestingly, the survey also found that respondents felt under pressure from other factors to look good, with 68% citing friends, 58% social media, 53% advertising, and 49% celebrities.

Another disturbing aspect is how a performer’s body shape is changed digitally. Victoria Hesketh, who performs under the name Little Boots, has drawn attention to the use of photoshopping to alter the appearance of artists, citing the case of the singer Meghan Trainor, herself a campaigner on the misuse of body image, whose 2016 video “Me Too” had been digitally manipulated to reduce her waist size without her express consent. Ms Hesketh commented in an article in The Independent:

“This stuff is nothing new, but I’m not sure if people really realise the extent to which image manipulation really matters, especially in pop music videos and even more so with female artists.”

She continued:

“I remember a music video director once telling me”— this is really shocking—

“‘You should have seen Beyoncé’s ass before we got in the edit’.”

Let us think about the implications of what the editor in those circumstance thought was his responsibility. It is quite frightening.

In 2011, as part of their “Pretty as a picture” project, Jo Rigby and the advertising think-tank Credos commissioned Panelbase to conduct an online survey of 1,000 girls and young women aged between 10 and 21. Since that time, the fashion industry has become significantly more sensitive about body shape for models, which is to be welcomed. The survey found that 53% of young women took

“inspiration from adverts for their appearance”, and that 37% wanted to

“look like models they see in adverts”, even though 85% of them

“recognise that...images in advertising have been altered using airbrushing.”

Worryingly, about half of the young women involved admitted:

“Seeing adverts using thin models makes me want to diet/lose weight/feel more conscious of the way I look.”

On the issue of social media, Girlguiding UK’s “Girls’ Attitudes Survey 2019” concluded:

“Girls and young women say they’re aware of the difference between real life and what they see represented online and in the media. Almost half of girls regularly remind themselves that social media is not a real reflection of others’ lives. One solution may be making sure airbrushed pictures are always labelled as such, with over half of girls agreeing to this. Nearly half of girls agreed there should be a more diverse range of people on screen too.”

My point in citing those examples is to make a connection between what we see and the reality of young people trying to emulate the stars that they see as role models, which I described earlier as being a vicious circle.

Another pressure turbocharges this phenomenon—namely, the way in which social media can serve as a means of shaming people about their appearance. I confess that I find that to be an ethical minefield. In an open society, we rightly defend the principle of freedom of speech, but when that freedom normalises abuse and shaming, the platforms and the individuals who use them surely have to take responsibility for what is said and the potential consequences. What might seem a bit of fun can very easily have devastating consequences when it targets people in such a way as to drive them towards eating disorders.

In last week’s New Statesman, Amelia Tait wrote about personal responsibility for those who engage with social media. She stated:

“It’s not up to algorithms to change our behaviour, it’s up to us. We have to stop celebrating cruelty with our clicks, and instead make a conscious effort to reward people who are kind to others or people who call out poor behaviour when they see it.”

Social media platforms need to recognise how they can profoundly affect people’s mental health and behaviour. Either they accept that responsibility or, sooner rather than later, they will have to be regulated to do so. We all have an important role to play through the language we use. When we say things such as, “You need to grow a thicker layer of skin”, or “Get a grip”, that is not helpful. The effort required to tackle an eating disorder of any description is profound and massive. Simply telling people to “get a grip” does no good at all.

I said earlier that I am indebted to the charity Beat, among others, for its help in preparing for this debate. Its key policy suggestions are based on the current treatment available for adults, treatment for young people, medical training and research funding. My constituent Emily helps raise funds for Beat and has organised sponsored walks with her family and friends, which I have been pleased to support and I am probably healthier for having taken part.

Beat has pointed out:

“Adults with eating disorders in England face a postcode lottery” in trying to access treatment. Only 26% of adult patients commenced treatment at a specialist service within four weeks of being referred. The average wait is nine weeks. In some clinical commissioning groups, adults are first referred to a non-specialist health service or to a panel for approval before being referred to a specialist service. That inevitably creates delays, which in some cases can have tragic consequences.

Beat and the Royal College of Psychiatrists suggest that a funded access waiting time standard should be introduced for all adults with eating disorders in England. An access and waiting time standard has already been introduced for the treatment of young people with eating disorders. By 2020-21, it is hoped that 95% of children and young people will commence treatment approved by the National Institute for Health and Care Excellence within one week of referral for urgent cases and within four weeks for less urgent ones. The most up-to-date information across clinical commissioning groups, however, shows that the rate for meeting the urgent referral target varies between 22% at worst and 100% at best. Beat is calling for the access and waiting time standard for children and young people with an eating disorder to be met in every area across England.

A further concern raised by Beat is that eating disorders are not sufficiently covered during medical training. On average, medical schools spend less than two hours teaching about eating disorders. One in five provide no training at all, and many do not even include a question on eating disorders in their final exams. As one fourth-year medical student put it:

“We don’t get any clinical skills experience.”

For those reasons, Beat recommends:

“Eating disorders are appropriately taught and assessed at all medical schools”, and that all junior doctors in the UK

“gain...clinical experience during their foundation training.”

The Royal College of Psychiatrists has called on the Government to double the number of medical school places in order to provide the specialists needed to help people with eating disorders. I echo that call.

Beat’s final point relates to research funding. Given that the broader category of mental health accounts for 23% of NHS activity in 2018-19, 10% of the Department of Health’s research funding goes to mental health research, with just 0.09% devoted to eating disorders. That amounts to 96p per sufferer, compared with £228 per person spent on vital cancer research that has led to survival rates for cancer doubling over the past 40 years. I mention that not to suggest that too much money is being spent on cancer research, but because it shows that if more money is put into research, results follow. Beat is calling for a “significant increase” in funding for research into eating disorders.

Hope Virgo of the Dump the Scales campaign last week launched the z-cards campaign, a guidance resource for those with eating disorders and those supporting them. It has the timely and important aim

“to raise awareness of eating disorders” and provide

“an educational piece for all frontline staff.”

Dump the Scales is asking the Government to recommit to NICE guidance 1.2.8:

“Do not use single measures such as BMI or duration of illness to determine whether to offer treatment for an eating disorder.”

The Royal College of Psychiatrists makes the same point. Hope Virgo is also calling for support for the roll-out of the z-card, training for GPs on eating disorders, and the development of a meaningful way of measuring the implementation of the guidelines, together with an annual implementation review.

I want to deal with the question of the best form of treatment for eating disorders. I have spoken to many people who have experienced them, and some believe that long-term residential treatment, sometimes including cognitive behavioural therapy, has been beneficial. There is, however, no consensus about cognitive behavioural therapy. Some experienced psychiatric specialists argue that although it may be a short-term way of dealing with the immediate problem it is not necessarily a long-term solution, in that it does not address the underlying cause of the disorder. I do not intend to draw any conclusions on that difference of professional opinion because, frankly, I do not feel equipped to do so, but I will refer back to the matter shortly. Some treatments at private healthcare facilities have been cited as having a positive effect on people’s eating disorders. However, such treatment can be very expensive and is usually beyond the means of most sufferers and their families.

Sandie Atkinson of Diabetics with Eating Disorders has said that there is still a desperate need to make insulin omission for weight loss, also known as diabulimia, a diagnosable condition. DWED supports the use of “type 1 eating disordered”, or T1ED, as an umbrella term for all disordered eating occurring in type 1 diabetes. The diagnosis would include subcategories for anorexia, bulimia and diabulimia, as insulin omission can occur separately or alongside other eating disorder symptoms.

I have a number of questions I want to address to the Minister, although I do not necessarily expect answers to all of them today. First, will she give careful consideration to the suggestions that DWED, Beat, and Dump the Scales have made about eating disorders, and will she undertake to respond in some form of written statement when she has had the opportunity to look at them more carefully? Secondly, will she undertake a review of the long-term effectiveness of cognitive behavioural therapy to assess its efficacy for treating eating disorders? Thirdly, will she undertake to meet representative bodies of the entertainment industry, Equity and the Musicians’ Union, to discuss the relationship between the promotion of a certain type of body image and the way in which it can affect young people? Finally, will she hold a similar meeting with social media providers to discuss what more they should do to prevent their platforms from enabling abusive behaviour, which shames some young people into acquiring eating disorders?

I hope we can agree that the issue of eating disorders is in need of urgent attention, not least because of the serious implications it has for the health and wellbeing of so many people and their families.

It is a great pleasure to follow my right hon. Friend Sir George Howarth. I call him my right hon. Friend because I have been working with him on diabulimia. He has huge expertise in the area and I am rather new to the field. I shall be brief.

We are all occasionally touched by surgery cases we get, and about 10 months ago a couple came to see me whose daughter had recently taken her life after a long battle with diabulimia. It is terribly distressing to talk to parents who have lost a child to suicide, and perhaps even more so given the terrible background to that suicide—although all suicides are to be mourned equally. The Minister has been fantastic. I have been in correspondence with her about the case, and about diabulimia.

For the record, I shall give a quick overview of what led to the tragedy of a young woman aged 27, who was a teacher, taking her own life. She had suffered with eating disorders for a number of years and was diagnosed with type 1 diabetes. As her parents said, she became giddy with joy. This is not a normal reaction when someone is diagnosed with diabetes. She was giddy with joy because she realised that as a sufferer of diabetes, she could suppress her weight through insulin abuse. In her parents’ words, the prescribing of insulin weaponised her eating disorder.

The concern that I and the young woman’s parents have, which I have raised with the Minister, is that too many healthcare professionals are unsighted in this area. When they prescribe insulin to an adolescent female or young woman, they are not alive to the risk that there may be an undiagnosed or undeclared eating disorder, or an underlying risk of an eating disorder, and that what is actually happening is that someone with a severe condition, or a propensity to a severe condition, is being handed a toxic substance that might save their life in one way but lead to the loss of it in another. There is a need for really strong background discussions with young women and girls when they are diagnosed with type 1 diabetes about their mental wellbeing and whether there is any danger of an eating disorder being present.

I have taken the case up with the Minister and I pay tribute to her. She is aware that the NHS is currently piloting services joining up treatment for diabetes and for eating disorders in London and on the south coast. Our most recent correspondence was last summer and I hope that, if not today, at some stage the Government will be able to update the House as to the success of the pilots and whether they will lead to a wider roll-out.

As the Minister said in her letter, the pilots will provide a valuable insight into the impact insulin prescribing has on individuals at risk of developing eating disorders, and they are an important step forward in recognising and treating diabulimia and minimising its devastating impact on patients and their families. That is exactly what we want to hear from the Department of Health, and I congratulate it on recognising the scale of the problem. The Minister went on to say that raising awareness among health professionals and alerting them to the risk associated with insulin and eating disorders is one of the Government’s priorities.

The debate is hugely timely. I hope that further measures will emerge from it across the NHS—across GP and mental health surgeries—that contribute to ensuring that no families have to lose a child in the way my constituents did.

I thank Sir George Howarth for bringing the debate forward. I am pleased to participate in it. I, too, have had constituents who have had eating disorders over the years, so this is an opportunity to highlight those issues and look to the Minister for a positive response—no doubt we will get one. It is good to follow Sir Charles Walker, and I thank him for his contribution. Until the right hon. Member for Knowsley told me about it some time ago, I was not aware of the issue of eating disorders among people with diabetes.

It is good to have the opportunity to speak about eating disorders, which are serious mental illnesses that deserve to be dealt with in that vein. My interest in the issue came from sitting with a friend of mine—a father who was at his wits’ end trying to get his daughter, who was suffering from an eating disorder, the help she needed. That was way back when I first came here, between 2010 and 2012. He did not give up. Neither did I—and neither did the Minister responsible for health back in Northern Ireland or the Health Minister here. It was a combination of both that brought about the success that we had hoped for. The Minister in Northern Ireland managed to make changes to how things were approached there. The result of that was that we—not me, but the Minister at the time—made legislative changes and changes to the provision of in-patient care specifically for those suffering from eating disorders.

That story is very poignant. I will not mention any names, but that young lady had severe eating disorders. Unfortunately, she had hidden much of it from her parents, whom I knew extremely well; they both were in an occupation that I had a particular interest in. They had approached the Department of Health back home but had not really got the response they wanted, so I met Edwin Poots, who was Health Minister at that time. Ultimately, through our contact with him and the Health Minister here, we were able to get that young lady over from Northern Ireland, where there did not seem to be anything in place to help, to St Thomas’s Hospital just across the way from where we are now. Ultimately, the medical care it was able to offer saved that young girl’s life. It is as simple, as graphic and as honest as that. I would like to put on the record my thanks to the Minister at that time and to St Thomas’s for giving that family the treatment and help they needed.

The wonderful thing about that story—again, I will mention no names—is that that young girl is now married. She is still one of my constituents, as indeed are her mum and dad, and she has two young children. I had not seen her for a few years, but before the election I knocked her door. She came to the door looking extremely well, and she reminded me of that story. I wanted to tell it today to add to the interactions described by the hon. Member for Broxbourne and the right hon. Member for Knowsley. Things can be changed if the right measures are in place to make that happen.

I asked the Minister back in January how many people were recorded as having had eating disorders over the past five years. The answer was not straightforward. That moves us to the crux of the issue: the differing diagnostic processes. The Minister’s response read:

“The following tables show the number of people referred to specialist secondary mental health services with a primary diagnosis of eating disorders from 2014/15 to 2015/16, and the number of people referred to specialist secondary mental health services with a primary reason for referral of eating disorders from 2016/17 to 2018/19.”

The figure was 4,513 in 2014-15 and 3,895 in 2015-16. The source for those two years is the NHS Digital mental health and learning disabilities dataset. In 2016-17, the figure jumped to 11,207, and in 2017-18 it increased to 18,224. In 2018-19, there was a massive jump of more than 4,000, to 22,336.

The Minister’s answer continued:

“There are two matters to consider when looking at the MHSDS data:

Diagnosis recording is known to be low. Of the people in contact with these services on 31 October 2018, for example, a diagnosis was recorded for only 22.3% of people. Therefore, the number of people with a primary reason for referral of ‘eating disorders’ for 2016/17, 2017/18 and 2018/19 is provided, rather a count of people diagnosed with an eating disorder.”

That probably means that in 2014-15 and 2015-16 a large number of people had similar problems but were not referred. That is what the Minister acknowledged in her response. If we have a problem even counting how many people have a disorder, how on earth do we find them the help they need?

The charities that work with those struggling with their eating are a little clearer about how they work things out. The right hon. Member for Knowsley referred to Beat—I thank both it and the Library for the information they sent us—which estimates that there are some 1.25 million people in the UK with an eating disorder. That is not in any way reflected in the Government’s figure of 22,000. If it is anywhere near the truth, Beat’s figure cannot be ignored.

Beat stated:

“The most common age of onset is 15-25 years old, during a developmentally sensitive time. Anorexia has the highest mortality rate of any mental illness, and the mortality rates of the other eating disorders are also high. People with eating disorders typically develop severe physical health problems and overall quality of life has been estimated to be as low as in symptomatic coronary heart disease or severe depression.”

That demonstrates the magnitude and severity of the issue. Beat continued:

“Without early intervention, many become unable to participate in education or employment.”

Some 1.25 million people in the UK currently live with an eating disorder, while 10% of people affected by an eating disorder suffer from anorexia and 40% suffer from bulimia. The rest of sufferers, including those with binge eating disorders, fall into the “other specified feeding or eating disorders” category. There are some very complex examples of those problems.

Research suggests that the earlier treatment is sought, the better the sufferer’s chance of recovery. That is the case with almost every disease: early diagnosis always helps to address something early, solve problems and raise awareness. Some 50% of eating disorder sufferers go on to recover. That is encouraging, but it tells us that 50% continue to have problems. Only 30% improve, and 20% remain in a chronic condition; many continue to suffer way beyond their alarming early conditions. Those high figures highlight the serious issues with the availability of holistic treatment.

I wholeheartedly support the Dump the Scales campaign, which would bin the GP regulations enforcing a minimum weight or BMI before a diagnosis can be given. Indeed, I support calls for GP retraining on this issue. I am very respectful of our GPs, who are wonderful people. They do great work, but sometimes we need a better understanding of eating disorders. We should not insist on certain categories in relation to eating disorders or insist that people get on the scales. I think it is important to address that.

I am a type 2 diabetic. Whenever I go down to the doctor, he weighs me and refers to my BMI, and he tells me whether I am on the right or wrong side of it. Thank goodness, this last while I have been on the right side of it. I try to keep careful control of what I eat and how much I eat.

When a parent, a carer or a sufferer themselves realises that all is not okay with their mindset towards food, palming them off with a little leaflet or a referral—I mean this respectfully—to yoga classes, as sometimes happens, is not enough. I am not saying that yoga is not good to do—I have never done it and have no knowledge of it—but to say that that is a way to solve someone’s eating disorder is a wee bit crass, to say the least. We must get on with early diagnosis and intervention, rather than effectively saying to people, “You aren’t skinny enough yet to merit help,” because they are.

The starting point must be the first realisation that there is a problem. When the parents of the young girl I mentioned earlier realised that their daughter had a problem, they addressed it early on. A doctor has never asked me to be tired for six months before checking the iron in my blood. He carries out a test to ensure that nothing is wrong. We start at the beginning and do not waste six months to see what it is. Why must we wait until someone is dangerously underweight before we offer them help when, in some cases, that is just too late?

I am fortunate to have two granddaughters who are extremely beautiful, not like their grandfather—and they will be glad to hear that; they have their grandmother’s and mother’s good looks—but never do I want them not to see what I see when I look at them. If, God forbid, there was a problem, I would want to know that the NHS had not simply the finance but, more importantly, the understanding of how and when to intervene. That is not simply when the scales show the correct small number.

It is a pleasure to serve under your chairmanship, Mr Rosindell. I thank Sir George Howarth for introducing the debate, particularly in Eating Disorders Awareness Week, on such an important issue that is often overlooked because it is hidden. He was fastidious in detailing so many of the crucial aspects of eating disorders and how our popular culture impacts on so many. I think it will go on to affect more young people as it grows under the social media stresses and pressures put on them.

I was thinking back to when I first started to think about appearances, which was probably when I was in my mid-teens, but my daughter, aged 11, is already looking on Instagram and so aware of how she looks and how many friends she has on social media. Those are not what I would call actual friendships, but these days it is all about social perception, and the pressures and stresses we put on young people through social media, which remains largely unregulated, are astronomical. We are creating a mental health catastrophe that is coming down the line for our young people. It will impact on men, who are not immune, but it impacts significantly on young women. I see that in young children of primary school age: my daughter and her friends very much relate to pictures of one another online and how they look. A societal image of perfectionism is being created that is very unhealthy for people’s mental health.

Eating Disorders Awareness Week is running this month, raising awareness of a disorder that, as has been said, affects 1.25 million people across the UK. When I worked as a psychologist in mental health services, I was aware how even then it was not a key focus in our training. Mental health professionals could benefit from much more in-depth training in eating disorders. When I was at Glasgow University, we benefited from the psychologist who came to train us having a specialist interest in the area. He is long retired and I do not know if anyone has taken his place, but training was very much dependent on individuals who had developed specialist expertise coming and lending that expertise, because those in training may not meet or have clinical experience of treating people with eating disorders unless they go on to do a specialist placement. Many of the professionals we are bringing through across the United Kingdom will not necessarily feel that they have sufficient expertise to treat eating disorders. We need to address that, particularly because, as has been said, it is not the kind of difficulty where people often come forward and say, “I have an eating disorder.” Clinicians, trying to form a picture on presentation of someone who might come with a diagnosis of depression or trauma, may notice a larger clinical picture not in the referral, but they require that expertise to pick up those symptoms early on. We know that earlier intervention creates a much better outcome for those with these conditions.

The other important issue I want to bring up is the Dump the Scales campaign, which I looked at while other hon. Members were talking. There may be more obvious signs of weight loss in individuals who present with anorexia, but those with bulimia are often bingeing and then purging, so there may not be noticeable weight loss. Such disorders can become extremely chronic before anyone picks up the symptoms. Certainly, one symptom of the disorders is denial and attributing difficulties elsewhere.

Dump the Scales is important, because my understanding is that BMI has to be at a certain level for a referral. We need to move on from that in clinical practice and look much more widely. I have just looked up the criteria in ICD-10 and, while they may have moved on, there are a number of symptoms and BMI is one of them. That needs to be considered, because, as I said, the person is not likely to come with a presentation of eating disorders in the first place and then, if some of the clinical symptoms are so stark that they cannot be referred on to appropriate services so quickly, that creates another barrier to getting the treatment they so desperately need.

Family support is another matter that we often overlook but need to focus on. We really need to get family members on board in order to have holistic treatment, particularly for young people’s mental health. It would be helpful to know more about what is being done in relation to family systems therapy and family therapy.

I was trained in the cognitive behavioural therapy model when I was practising, but it was very much a formulation-based model. I do not think eight sessions of CBT would necessarily be effective for people who have a long-standing chronic illness or perhaps other underlying issues such as trauma that need to be resolved. We need a flexible system to ensure that a person’s care pathway is at the level of service they need for the chronicity of their difficulties.

It has not passed me by that it is International Women’s Day this week, so it is apt to have this debate on eating disorders awareness, which an issue that is likely to affect so many young people—overwhelmingly women, but also men—who face this social pressure.

I will finish with a few things that the Scottish Government are trying to do. This is an area where we should share best practice and have much collaboration across the UK, and I would like to see that and be part of it. It is excellent for the way forward that an all-party parliamentary group has been reconstituted.

Last year, the Scottish Government created an online peer support tool specifically for this issue to allow young people to pair with a trained volunteer, who had themselves recovered from an eating disorder. That is important because peer-to-peer support can be extremely helpful, particularly for young people. At certain stages in life we may speak to our parents more or less readily, depending upon our stage of development, and for adolescents, among whom a higher percentage of eating disorders initially develop, peer-to-peer support will provide an excellent starting point for treatment.

The website caredscotland.co.uk is an information platform for parents and carers. We must ensure that parents and carers, who are, most often, going to be the ones who pick up the initial signs, have awareness, as well as the support they need. It is vital that parents and carers have that support because dealing with an eating disorder can take an enormous emotional toll upon an entire family. We need to look at people’s mental health in a holistic manner.

We need to do much more, right across the United Kingdom, in relation to access to treatment for those who have eating disorders. We have come some way, but we need to raise more awareness at different levels within the system. GP training has been mentioned. We also need a public awareness campaign, because often peers or families pick up the initial symptoms, and medical training for psychiatrists and those working in mental health. From my own training, I do not think those professionals have the level of training necessary to treat people in primary mental health care, which is often where an eating disorder might be picked up initially before it is referred on to secondary community mental health teams.

I am thinking about the dangers of social media and how it affects children and young people. Could the dangers of social media be made clear at an early stage, perhaps at school? The perfect body, clothes, hair and everything become things everyone wants, whereas the reality of getting them is quite different. For instance, in some photographs, models’ six packs or their weight are actually changed digitally. Social media has a lot to answer for.

The hon. Gentleman is entirely correct. Social media often creates a false world that none of us can ever live up to. That is why I welcome the Government’s work on social media, which is looking at potential regulation and other issues in relation to the impact on mental health.

This is an excellent pivotal debate, but it is not the finishing point. It is most definitely the starting point for taking these issues forward on a cross-party basis. I look forward to working with everyone who has an interest in this field, to support progress for those who have eating disorders across the United Kingdom.

It is a pleasure to speak in this debate with you in the Chair, Mr Rosindell. I congratulate my right hon. Friend Sir George Howarth on securing this important and timely debate, and for the excellent way he opened it, which was very helpful. It has been a compact debate, but he covered a wide range in what he said.

I welcome the contributions of Sir Charles Walker, particularly when he spoke about the moving case of his young constituent who took her own life, which is always sad to hear; Jim Shannon, and the SNP spokesperson, Dr Cameron. I agree with her about using the debate today as a starting point. There is much that we should be talking about.

As we have heard, eating disorders are serious mental illnesses that affect too many people in this country. It is estimated that there are currently 1.25 million people in the UK with an eating disorder. It is a serious issue that we should be talking about, even more so because that is only an estimate as we do not have reliable data on the prevalence of eating disorders in the UK. The hon. Member for Strangford talked about that; it is an issue that we must take forward from the debate today. It is part of a broader problem with our data on mental health conditions, although we must acknowledge that some of it comes down to the stigmatisation of eating disorders.

Eating disorders can affect people of all ages, from instances among children as young as six years old, which should alarm us, to women in their seventies. Around three quarters of people with an eating disorder are women but, as we have heard in the debate, eating disorders also affect men. We need to be careful not to stereotype when we describe people affected by eating disorders because it can deter men and young men from seeking help.

Anorexia has the highest mortality rate among all psychiatric disorders because of the severe medical complications that it can cause, but all eating disorders have an impact on the daily life of people who live with them. It is vital that eating disorder services are there to support people when they need it. It is my belief that too often people with eating disorders are being let down by our NHS, and those of us who are interested in this must take that forward from here.

Someone with an eating disorder will currently wait an average of three and a half years before receiving treatment. Too often someone goes to their GP to ask for help, but simply does not get it, as we have heard. The eating disorder charity Beat, which we have all rightly mentioned in our speeches, found that nearly one in three people who seek a referral to an eating disorder service did not get one from the first GP to whom they spoke. These delays clearly go against the NICE guidance on ensuring prompt access to specialist services, and they come with an enormous emotional toll for the person involved. The hon. Member for Broxbourne talked about where that emotional toll can take somebody. Imagine having finally built up the confidence to go and ask for help only to be told, “You won’t get to see a specialist”.

Earlier this week, I spoke to people who are now recovering or recovered from eating disorders, who told me about their struggles to get support. I thank Beat for organising that meeting with MPs. One person was told by a doctor that she weighed too much to have treatment for an eating disorder, despite weighing only 38 kg, which is less than 6 stone. Let us imagine that weight. I also heard about a doctor praising over-exercising, as if that were a good thing. We heard from my right hon. Friend the Member for Knowsley that Mel C had the problem of obsessively exercising, which is another way people can seek to lose weight. Finally, a person was told that she needed to find the willpower just to eat. My right hon. Friend rightly criticised the attitude of underestimating the difficultly of the condition and the danger of the “just get a grip” attitude. We have to get over that and clearly it is even more damaging when it comes from clinicians.

People with bulimia have been denied treatment based on the frequency, or lack of frequency, of their bingeing and purging episodes. The continued focus on weight that we have talked about is particularly concerning as bulimia, along with other over-eating disorders, does not always lead to excessive weight loss. My right hon. Friend and the hon. Member for Strangford talked about Hope Virgo, the campaigner who leads the Dump the Scales campaign. That campaign tells us that clinicians are still using measures such as BMI to assess whether someone is eligible for eating disorder treatment, as I was told by the young person I met this week.

That is another instance where NICE guidelines are not being correctly followed, meaning people are being turned down for the support they should receive. Is someone who has been told they are ineligible for help after visiting their GP really going to go back and ask again and again, until they get the help they need? Or are they going to struggle with their eating disorder, potentially deteriorating to the point where they need to be admitted to hospital?

We should emphasise that the situation is not necessarily the result of medical professionals not caring about eating disorders, but a reflection of the fact that medical schools have less than two hours’ training on eating disorders across the average medical degree. In fact, one in five medical schools do not cover eating disorders at all and, where they are covered, the subject is not in the final exam, meaning students will give it a lower priority.

We see doctors who think people cannot have an eating disorder if they have a healthy BMI, family GPs who are not confident that they should make an urgent referral to a specialist service and many doctors who have never seen a patient with an eating disorder before. The Parliamentary and Health Service Ombudsman and the Public Administration and Constitutional Affairs Committee have both recognised this and call for all doctors to receive proper training on eating disorders. The General Medical Council has said that it will engage with medical schools on the lack of training, but that is a long way from guaranteeing that all newly-qualified doctors will have basic levels of knowledge on eating disorders.

Will the Minister act as a champion for improved training on eating disorders, so that patients can see a doctor who has a basic understanding of what an eating disorder is and of how important it is that a patient sees a specialist? That would be a first step in ensuring that the NHS gives people with eating disorders the support they need. I say a first step, because even when people can secure a referral to a specialist eating disorder service, there is no guarantee that they will then get the help they need.

Colleagues have brought a number of statistics into the debate. In 2017-18, an adult referred to a specialist eating disorder service could expect to have to wait an average of nine weeks to start treatment. That is clearly not good enough. In no other area of mental health would we accept a wait of more than two months to see a specialist. The Government seem to have accepted that in the case of children and young people, where we are finally seeing the introduction of waiting time targets, but waiting time targets for adult services are still being piloted. Can the Minister tell us why that is the case and when the Government will introduce waiting time targets for adult eating disorder services, to ensure that everyone can access timely support?

Simply setting targets will not solve this problem. I am afraid we are seeing that in services for children and young people where, despite some progress since the introduction of targets, people with eating disorders still face a postcode lottery up and down the country. In my constituency, 97% of young people referred to a specialist eating disorder service are seen within a month, but if they live just yards away, across the border in Wigan, the chances of their being seen in that timeframe fall to 66%. That is not good enough. We need all areas of the country to be given the resources they need to give people with eating disorders appropriate and timely support.

Sometimes the right support can mean the person with an eating disorder getting hospital treatment, but there are only 649 specialist in-patient beds for people with eating disorders in England, and just 249 of those are for children and young people. According to NHS data, the most common age for admission to hospital for eating disorders is 13 to 15. More than 4,400 children were admitted to hospital for eating disorder treatment last year.

When their local hospital does not have enough beds, children are being sent miles away from their families for special treatment, because the NHS does not have the resources to treat them closer to their homes. My right hon. Friend the Member for Knowsley also raised the issue of the use of private healthcare companies and private hospitals; too often, in the case of beds not being available, the NHS relies on private healthcare companies to deliver the services. My concern is that many of those services have been falling well below the standards expected. Some 28 privately-run mental health units have been rated as inadequate by the Care Quality Commission in the past three years. Vulnerable people with mental health conditions deserve much better.

Another issue worth mentioning is that the available treatment does not match the length of duration of adult eating disorders, even when a patient can have treatment. Two thirds of adult eating disorders last for three years or longer, but the current NICE-recommended adult out-patient therapies span only one year, or something like 20 to 40 sessions, 30% of which will be in-patient services. Fewer than 20% recover. There is a mismatch in the resources, there is a mismatch in the number of beds and there is a mismatch in the length of time that therapies last. If we catapult somebody out of a service before they are recovered, then clearly there will be a relapse. We need more research on that, and the NHS needs more mental health beds to cope with demand.

My final point is that services also need to be properly funded. The Minister will know that for too long we have seen money intended for mental health services diverted to meet other short-term financial concerns in the NHS. Given the pressure on NHS services now that we have the coronavirus to deal with, one can see that there will be even greater pressure not to spend money on mental health, but to spend it on other services.

Until mental health funding is both increased and ring-fenced, mental health services will remain a lower priority than patching up buildings, meeting demand for physical health services or even increasing services to deal with coronavirus. If we want to see eating disorder services improve, we must do everything we can to ensure that mental health services are properly funded, starting with increasing and then ring-fencing the funding.

It is a pleasure to serve under your chairmanship, Mr Rosindell. I congratulate Sir George Howarth —my right hon. Friend, if I may call him that—on securing this important debate on eating disorders awareness during Eating Disorders Awareness Week.

This is a subject close to my heart; it is a subject that we talk about frequently over at the Department and it is on the desk. It is so important because, as I think Barbara Keeley mentioned, the morbidity rates among young women suffering with eating disorders are the worst of any mental health issue. It is the most serious of all mental health issues that children and young people, and indeed adults, can suffer from. That is why it has such a high priority within the Department.

People with eating disorders often suffer in silence, but Eating Disorders Awareness Week brings this important issue out into the open and provides information and advice for those who seek help. I pay tribute to all those who are working hard to raise awareness of eating disorders, in particular the charity Beat, which hon. Members will know is supported by the Government and does so much to support young people through its helplines and support groups. I have met with Beat and I am incredibly impressed by the charity. It does incredibly good work.

We also have passionate and committed individual campaigners such as Hope Virgo, who has been mentioned a couple of times today. They are also doing much to raise the profile of eating disorders and to show people who are suffering from an eating disorder that, as hard as that is, it is possible to fight them and to get well.

As I have said, eating disorders are serious and life-threatening conditions; they can be devastating for those who are suffering, their family members and the people around them. That is why we want to ensure that people have access to the right mental health support in the right place and at the right time. Improving eating disorder services is a key priority for the Government, as I have said, and is a vital part of our work to improve mental health services. We know that the earlier an intervention is made and treatment provided, the greater the chance of recovery.

The waiting time figures for child eating disorder appointments in London show 97.1% of urgent cases being seen within one week and 92.8% of routine cases being seen within four. In my constituency, the figures are 78.6% and 78.3% in the same circumstances. Does my hon. Friend the Minister agree that, as part of our great levelling-up agenda for this country, the young people in my community in Rother Valley and across South Yorkshire deserve the same waiting times for eating disorder services as Londoners currently enjoy?

I thank my hon. Friend for that intervention. I will go on to talk about waiting times, but he is absolutely right. It is a trial that we have rolled out to ensure that, across the country, anybody who presents with a serious first instance eating disorder is seen within one week and routine cases are seen with specialist help within four weeks.[This section has been corrected on 19 March 2020, column 12MC — read correction] That has been rolled out and tested across the country by NHS England, and I am incredibly impressed at some of the statistics that I am hearing; I thank the hon. Member for Worsley and Eccles South for citing her own constituency.

This is a trial and, as we know, everybody has yet to meet the standards; that is the responsibility also of the clinical commissioning groups, because this is quite complicated.[This section has been corrected on 19 March 2020, column 12MC — read correction] I will go on to talk about that, but I am actually impressed even with those statistics, considering what it was like before. I am pleased to hear the figures that my hon. Friend Alexander Stafford quotes for his constituency, but they do have to be, to quote a phrase, “levelled up” along with everywhere else.

We know that the earlier an intervention is made and treatment provided, the more successful it is. One of the services in our mental health profile, which is not focused on eating disorders but which I am particularly impressed with, is the trailblazer schemes that we have rolling out into schools. Staff working on the schemes can pick up young people’s eating disorders at the very first signs. Outcomes are promising if they intervene at that very first stage, because the pattern of behaviour does not become established or embedded. They can intervene very early on.

On the point from my hon. Friend the Member for Rother Valley, we set up the first standard to improve access to eating disorder services for children and young people to ensure that, by the end of 2021, 95% of all children and young people with an eating disorder will receive treatment within one week for urgent cases, and within four weeks for routine cases. We are on track to meet that commitment, and figures I have seen today suggest that we may be on track to meet it early, which would be fantastic.

The number of people seeking treatment for eating disorders is sadly rising—or maybe it is a good thing, because people are not so stigmatised, are aware that help is there and are seeking it. However, that rise makes even more encouraging the corresponding increase in the number of patients who actually receive the care that they need. In-patient treatment should be a last resort, which is why in 2014 the Government announced a £150-million investment to expand community-based eating disorder care. We are making good on that promise, and as a result, 70 dedicated new or extended community services are now open or in development.

Indeed, I visited one myself and met the amazing staff who work there—it takes incredible skills to work with people who suffer from eating disorders—and some of the sufferers, and saw that work taking place. People who go into these units are usually there for quite a while; it takes some time to work through this. However, the outcomes looked incredibly promising, particularly for the young women I spoke to. The fact that we have 70 of those dedicated units open now, or about to open, across the country is an incredible step forward in addressing this problem.

That has led to sufferers receiving swift access to treatment within the community, because it is important that they receive treatment near to where they live, close to their families, schools and friends, and that their treatment causes as little disruption to their lives as possible. By improving care in the community, we can improve outcomes and recovery, reduce rates of relapse and prevent eating disorders continuing into adulthood, which is really important.

I thank the Minister for giving way; there is nothing more aggravating than somebody coming very late to a debate, but I have been in the International Women’s Day debate all afternoon. On relapse or eating disorders continuing into adulthood, does she agree that we have made massive strides forward in treatment for young people, but that there remains a problem of transition when sufferers turn 18? For those who develop an eating disorder slightly after their teenage years, or even well into adulthood, there is still a challenge in accessing services for those not eligible for children’s services.

My right hon. Friend makes an important point. That is why we invested £2.3 billion in mental health services, which, as I always say, is more than half the entire prison estate budget. We are focusing on young people and young women in this debate, but funding for mental health services is growing faster than the overall NHS budget. That funding and the development of community services is there to pick up exactly the cases she cites.

No mental health service, other than the very extreme, is better delivered in a hospital than in the community, whether for children, young people or adults. Despite that investment in community mental health services, our challenge is unprecedented, and our challenge is about workforce—it is about attracting people to work in this arena and to help us develop the community services that we need to provide treatment for adults and young people. That is the challenge we have taken on, and it is a challenge that we are meeting and moving forward with. It is our ambition and my absolute hope that children, young people and adults, regardless of their age—this illness is severe, whether in adults or children and young people—receive the treatment they require, when they require it.

These plans will require a close working relationship between the Department of Health and Social Care and the Department for Education. I am sure that that is what the Minister refers to, but will she confirm that that is the case?

Absolutely, and the Green Paper, which I am sure the hon. Gentleman will be aware of, references the mental health of young people in schools. However, it is also about the trailblazer schemes, peer support workers and other people who go into schools who specialise in how to identify this and pick it up. Teachers have a huge job, and I think if we were to say that they needed to pick up when someone is suffering from an eating disorder, they would probably throw their hands up, because it requires specialised training. It is a skill, and it takes careful handling when identifying someone who is suffering from an eating disorder. So yes, of course we work across Departments, but it is those specialised and trained mental health workers in schools who will pick this up.

We have a few moments left, so I refer the Minister back to the point I raised about relapse. We are largely talking about adults, and there is a mismatch between the average duration of an adult eating disorder—a large number of patients have severe and enduring illnesses—and the shortness of the therapies that they get. Professor Janet Treasure told me that a solution could be to increase the knowledge and skills of patients with those long, enduring conditions and their carers, so that they can self-manage the illness in parallel with clinical care. She is working on a pilot of that. I do not know if the Minister has heard about that, but I wanted to raise it as something that we ought to give attention to.

That is incredibly interesting. I had not heard about it, but I am sure that my officials will take note of it. We have an open door for anything that we can identify that helps us in targeting and providing services. We are looking for solutions to the problem. As I said, the money is there. Claire Murdoch, who I mention in almost every debate, and Professor Tim Kendall are rolling out mental health services across the country via NHS England. They have probably heard of it and are probably looking at it, but I am sure that we will take note and check if that is the case.

Although eating disorders are commonly first experienced by people when they are young, they can continue into adulthood. Following a report on how NHS eating disorder services were failing patients, NHS England convened a working group with Health Education England, the Department of Health and Social Care and other partners, which goes to the point that my right hon. Friend Caroline Nokes made. We are working in collaboration to address the report’s recommendations and to take them into account when planning for improvements to adult eating disorder services. Work is in progress on that.

We are continuing the investment in mental health services through the NHS long-term plan, as I think most people know. The £2.3 billion is with NHS England, which has a long-term plan to deliver on mental health and is moving at incredible pace. Even today, although it is not relevant to the debate, it announced the opening of gambling clinics across the UK. Community services are being rolled out across the UK so that people in mental health crises do not end up in casualty. It is an incredibly impressive roll-out of mental health services across the UK, including for eating disorders.[This section has been corrected on 5 March 2020, column 12MC — read correction]

That long-term plan will give an additional 345,000 children access to mental health support; 380,000 adults access to psychological therapies; and 370,000 adults access to better support for severe mental illness by 2023-24. It commits to the delivery of eating disorder waiting time standards, which I have already spoken about, and I hope that we will reach those before the end of next year. The plan has also committed to the design and roll-out of a new integrated model of adult community mental health care.

To increase further the number of people seeking treatment for their eating disorder, the Government recognise that raising awareness and reducing stigma are incredibly important. Here I should come on to a few of the points made by the right hon. Member for Knowsley. I shall go through them backwards, because that will be more positive in terms of affirmative answers. He mentioned social media providers, their role in body image and the impact that they have on young women. My right hon. Friend the Secretary of State for Health and Social Care has already—this happened recently—held a roundtable with social media providers. It was an incredibly positive meeting, but that is something that needs to continue, because when it comes to social media interactors, providers and platforms need to be aware of the impact that their forums have on young women, so we are continuing that dialogue with them and, I hope, are continuing to push that point.

The right hon. Gentleman made a point about the entertainment industry and its relationship and responsibilities with regard to body image. I announced two weeks ago that I am holding a roundtable with the entertainment industry. That was as a result of the death of Caroline Flack, who took her own life. For me, that was a watershed moment. It is time for the entertainment industry to be aware that it does not have a duty of care only to the people who they take on a contract to work with them. This is not just about sudden fame and reputation loss. The industry has a wider responsibility in relation to images that it projects and how it projects them, because young women and, indeed, many people absolutely are influenced by what they see—their perceived role models—through the lens of television or the cinema. The entertainment industry definitely has a responsibility, so in response to the right hon. Gentleman’s question, I can say that I have already put that in train.

In relation to a review of the long-term effectiveness of CBT, I defer to the expertise and knowledge of our friend from the Scottish National party, Dr Cameron, who made the point that short-term CBT may not be as effective, in terms of how it is delivered, for such long-term conditions. It may be part of the treatment, but as we know, when it comes to eating disorders, treatment is very prolonged in some cases. I am sure that CBT has a definite role, but it should not be seen in isolation. Management of eating disorders takes the input of physicians and psychologists—people who are expert in managing these conditions and working in this field. Therefore I would say yes, but not in isolation.

I thank the Minister for making that point. I think that there should very much be a formulation-driven treatment plan whereby all the issues that the person presents with are taken on board, and different aspects may require different parts of treatment. I do not think that often happens currently, particularly where people present to primary care services and perhaps do not get the specialist services that they need, but I hope the work that is being done will streamline that for the majority of people in the future.

I am sure that Claire Murdoch and Tim Kendall at NHS England are all over that and very aware of that. A streamlining approach to treatment is about getting people seen within the first week. If people are first seen within the first week when they present with their first crisis, that is the time when greater intervention can happen and when that treatment plan can be designed and put in place and there can be that entire care pathway through. I will not say that I think that that would shorten the illness, because I do not know. The hon. Lady probably knows more than I do, but I would think that an effective treatment plan with CBT and everything that is involved in that would provide a better outcome than piecemeal interventions along the way.

The right hon. Gentleman’s first point was careful consideration of Beat and so on. I am a huge admirer of Beat. It provides an incredible service. Its helpline deals with 30,000 people a year, I think, if I am not mistaken—it is a few weeks since I saw Beat. The support service that it provides, particularly to young women who are looking for someone to talk to and advice and help, is second to none. We are absolute supporters of Beat.

Let me just go on to the point made by my hon. Friend Sir Charles Walker about diabulimia. It is also of course the point that the right hon. Member for Knowsley raised repeatedly. We are absolutely committed to ensuring that people with diabulimia receive the treatment that they need. That is why NHS England announced in February 2019 the piloting of services. The services are being piloted on the south coast and in London, and NHS England will evaluate and monitor the pilots and take the learning from them. I will raise what the results show, if the results are through yet from the pilots, and what learning there has been and how it will apply across the UK.[This section has been corrected on 19 March 2020, column 13MC — read correction] I am sure that the officials will take a note, and when I have had that meeting, I will report back to the right hon. Gentleman and let him know exactly what the findings are and where we are going on that. The group that we are talking about is very small, but it is at the extreme end and requires very serious consideration.

I think that those are all the points that were raised and that I need to answer.

Absolutely. On training for GPs, I take the hon. Lady’s point exactly. The NICE guidelines are incredibly clear, in terms of the Hope Virgo campaign and taking BMI, weight and other things into consideration. The NICE guidelines are clear, and it is up to the clinical commissioning groups to ensure that GPs and others do not take weight as a consideration. Tim Kendall is all over this and is working on it. We want GPs and others to abide by what are already very strict NICE guidelines. We have the guidelines; we just need the medical profession to implement them, but I had an idea when the hon. Lady asked her question. We are talking about training for GPs with the General Medical Council and we will continue to hold conversations about that, and I am sure that NHS England is doing exactly the same thing, but there are quicker ways to get information through to GPs.

When I was a nurse and I was training, it was the Nursing Times that informed us, on a weekly basis, of what was new in treatments and operative procedures. For GPs, it is Pulse and other magazines that they receive. I think that there might be a quicker way into GPs’ surgeries to alert them to the fact that the NICE guidelines are not being applied by GPs or by clinical commissioning groups. I think that there may be more inventive ways around that. Yes, training GPs absolutely is important; it is important to include this issue in the GP training programme, but in terms of getting a message through to GPs now, I think that we need to look at a more innovative way of doing that.

On money being diverted and ring-fenced, I think that the hon. Lady knows that the money from the £2.3 billion that goes to the CCGs is ring-fenced for mental health services only. They are not allowed to siphon it off and use it for anything else. We have our own queries as to whether some are doing that, and I know that NHS England, because I raised this with it the last time I met it, is doing an evaluation of clinical commissioning groups and having a look and checking that that money, which is ring-fenced, is spent only on—

It is always a pleasure to talk to the Minister. I start by thanking everybody who took part in the debate. Sir Charles Walker spoke movingly on behalf of his constituents. As he knows, I have met them. They are a formidable couple who are trying to turn their grief into something positive, and I applaud them for that.

Caroline Nokes has been, along with me, ploughing this somewhat lonely furrow over many years. It is always a pleasure to have her as a combatant in the battle that we have been conducting. As ever, we saw the compassion of Jim Shannon, which is legendary—in this Chamber and elsewhere and certainly in his own constituency. Dr Cameron, who spoke for the SNP, made a very helpful contribution, as did my hon. Friend Barbara Keeley, who spoke from the Labour Front Bench. I will take the Minister up on her invitation. I am very grateful to everybody for contributing to the debate.